Herpes esophagitis

by Jason Wasserman MD PhD FRCPC
June 28, 2023

What is herpes esophagitis?

Herpes esophagitis is a medical condition caused by infection of the esophagus by herpes simplex virus (HSV). The infection leads to inflammation which damages tissue on the inside of the esophagus.

herpes simplex esophagitis
Herpes esophagitis. This picture shows squamous cells inside the esophagus infected with herpes simplex virus.

What causes herpes esophagitis?

Herpes esophagitis is caused by infection of the cells on the inside of the esophagus with the herpes simplex virus (HSV). Most cases are caused by herpes simplex type 1.

Who is at risk for developing herpes esophagitis?

People who have a weakened immune system are at risk for developing herpes esophagitis. A weakened immune system can be caused by medications such as those taken after a solid organ or bone marrow transplant, corticosteroids, or immune modulators, and HIV infection.

What are the symptoms of herpes esophagitis?

The most common symptoms of herpes esophagitis are difficulty swallowing or pain when swallowing foods or liquids.

How is herpes esophagitis diagnosed?

The diagnosis of herpes esophagitis can be made after your doctor examines the inside of your esophagus with a camera called an endoscope. During the examination, small samples of tissue will be removed in a procedure called a biopsy and the tissue will be sent to a pathologist for examination under the microscope.

What does herpes esophagitis look like under the microscope?

The cells that normally cover the inside of the esophagus are called squamous cells and they form a barrier called the epithelium. Infection with herpes virus damages these squamous cells which leads to a type of injury called an ulcer. Infected squamous cells may be seen at the edge of the ulcer and these cells have a unique look under the microscope. In particular, the nucleus (the part of the cell that holds the genetic material) may be enlarged, and the chromatin (genetic material) may be pushed to the edge of the nucleus. Infected cells may also have more than one nucleus (pathologists call these cells multinuclear) and blue/purple dots called intranuclear inclusions may be seen inside the nucleus. Inflammatory cells including lymphocytes and neutrophils are also typically seen around the infected cells.

What other tests may be performed to confirm the diagnosis?

Your pathologist may perform a test called immunohistochemistry (IHC) which allows them to see the virus inside infected cells.

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